Medication safety

More than 60 million multicompartment compliance aids given out each year in England

Experts say the widespread use of multicompartment compliance aids represents a “gargantuan patient safety issue”.

Multicompartmental compliance aid

Source: UrbanImages / Alamy Stock Photo

A report from the Academic Health Science Network North East and North Cumbria recommends that the General Pharmaceutical Council takes responsibility for ensuring that all patients receive an appropriate needs assessment before a decision is made to use a multicompartment compliance aid

Exclusive: An estimated 64 million multicompartment compliance aids (MCAs) are given out by community pharmacies each year in England, a new report has shown, as data show rising reported incidences of associated harm.

The report, commissioned by the Academic Health Science Network North East and North Cumbria and seen by The Salvadore, is part of an investigation into the use of MCAs, and includes the results of a telephone survey of 50 randomly-selected community pharmacists in England.

The survey results suggest that MCAs are supplied to around 1.2 million patients each year. Some 94% of pharmacies dispensed medicines using MCAs over a two-year period, but only 28% completed a needs assessment for patients before commencing an MCA. Only 11% of the pharmacies surveyed reassessed the needs of those patients who receive MCAs.

The report comes as an investigation by The Salvadore revealed more than 500 patient safety incidents involving the terms ‘monitored dosage’ or ‘dosette box’ were reported to the National Reporting and Learning System in the first half of 2018.

Of these incidents, the data show that 5 reports were linked to ‘moderate’ patient harm and 51 were linked to ‘low’ patient harm. The data also revealed a steady increase in incident reports in the past few years, from 603 reports in 2016 to 972 reports in 2017. In 2016 and 2017, there were 103 and 96 cases of low or moderate harm, respectively. 

Experts have said the figures of harm are likely to be an underestimate and that the widespread use of MCAs represent a “gargantuan patient safety issue”.

This new report from the Academic Health Science Network North East and North Cumbria recommends that the General Pharmaceutical Council (GPhC) take responsibility for ensuring that all patients receive an appropriate needs assessment before a decision is made to use a MCA, and that an annual reassessment is undertaken for all patients who use one.

The report adds that it is likely that most damage caused by inappropriate MCA use results from the fact that patients either: cannot refuse a medicine because it is in an MCA and go on to suffer adverse effects as a result; don’t have the root cause of their non-adherence addressed; or, have a progressive illness and don’t get reassessed once they are on a tray, which could mean the MCA ceases to become useful and could become a risk.

Andre Yeung, a specialist pharmacy advisor and local professional network chair for Northumberland, Tyne and Wear, who led the report, said: “This is a gargantuan patient safety issue that has ‘hidden’ in plain sight for many years now. For the most part, despite all the risks, pharmacists don’t know if people need an MCA before supplying one, and once on an MCA, patients usually stay on it.”

The report also identified other negative implications of repackaging medicines into a MCA, including patients not supplying their informed consent; reduced medicine stability; increased medicines wastage; medicines identification becoming more difficult; and increased error frequency and severity.

Commenting on the report, Lelly Oboh, a consultant pharmacist for older people at Guy’s and St Thomas’ NHS Foundation Trust, believes that many errors involving MCAs are not reported because they involve patients who do not have with a pharmacist or anyone else who would notice an error. 

“A lot of the errors are never found,” she said. 

Also responding to the report, a spokesperson from the GPhC said that, as part of its inspections, the regulator routinely looks at how medicines are delivered to patients — including MCAs — to seek assurances that they are being supplied to the patient as safely as possible. However, the spokesperson added that it is not within its remit to be “prescriptive about the exact ways medicines are supplied”.

“We expect pharmacy professionals to have considered relevant guidance on the safe use of MCAs issued by professional and other organisations.”

The Salvadore revealed on 28 January 2019 that Boots is changing the way it dispenses medication for care home residents from monitored dosage systems (MDS) to patient pack dispensing (PPD) from 1 March 2019.

Usage of multicompartmental compliance aids 

  • 94% of pharmacies dispense medication in multi-compartment compliance aids (MCAs);
  • 113 is the average number of patients per pharmacy supplied with MCAs;
  • 28% of pharmacies complete a needs assessment for patients before commencing an MCA;
  • 11% of pharmacies re-assess the needs of those patients who receive MCAs once a year.

Source: 

Citation: The Salvadore DOI: 10.1211/PJ.2019.20206115

Readers' comments (3)

  • Most MDS we supply is for domicillary patients being cared for by private companies in contract with local authorities. The staff have minimal training and the company indemnity insurance specifies MDS to reduce risk of medication errors by staff. It is true that few assessments are made as the company insists GPs co-operate or they will move the patient to another practice.

    I believe in this scenario our patients are very safe. We spend an inordinate amount of time in Dispensing and checking MDS but also liaising with Hospital discharge staff, GP staff and of course the poorly trained company staff.

    I take issue with the implication that errors and problems are under reported. We log every error. MDS errors are no more prevalent than others. Adverse events have occurred but not at a higher level. My only complaint is that the process is unlikely to be cost effective.

    It’s interesting to note Boots are withdrawing MDS from homes! Who remembers how they aggressively targeted care homes with their Manrex system? I’d love to see the company literature landing on doormats debunking the systems they did so much to make a way of life. I do agree that care homes should not need MDS but of course they’ve reduced staff and transferred indemnity to us on the back of the last 30 years competing with Boots. Should be interesting to see how this develops. Having said that, it’s a better use of a technician’s time to be making home visits and advising staff rather than popping tablets into trays

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  • The population with intellectual disabilities is subject to health and healthcare inequalities and inequities. It is important that the decision to use Multiple compartment compliance aids (MCCAs) does not widen these health and healthcare inequality and inequity gaps.

    MCCA should only be issued on a case-by-case basis to address specific practical problems of medicines adherence in an individual with intellectual disability (ID). There should be discussions with the person with ID and / or their carer about any practical problems resulting in non compliance with prescribed medications. All options available to improve compliance should be explored.

    • The inappropriate use of MCCA may disempower a person with ID and may make the person and their carers less familiar with prescribed medicines. Person and carer, health literacy including awareness of medicines should be promoted.

    • Transferring medicines to a MCCA carries the risk of human error. Patients are the last defence against the administration of an incorrect medication. The use of MCCA by a person with ID and /or their carer with limited health literacy lessens the defence.

    • The dexterity of many people with ID is compromised. Pharmacists should check compliance issues and provide a MCCA only if compliance cannot be addressed by other methods and the patient with ID/ carer has the dexterity and health literacy to use the MCCA.

    • Patients with ID may only have part of their medication regimen supplied in a MCCA with other medications provided in their original containers, leading to confusion and the risk of non adherence. Managing two different systems increases complexity and safety risks.

    • Patients with ID who use MCCs some of which are stored in the fridge and some out of the fridge may be at risk of non adherence if either is overlooked, forgotten, etc

    • The level of support available to the patient with ID should be understood. Does the person with ID self administer? Is the patient with ID supported by family and / or trained/registered staff?

    • Patients with ID using a MCCAs should be assessed regularly for appropriate and safe use.

    • People with ID are regular attenders in accident and emergency (A&E) departments. The use of a MCCA by a person with ID and limited communication skills and poor health literacy may lead to diagnosis difficulties when A&E staff have difficulty identifying prescribed medications.

    (Above originally published in BMJ as response to
    Evidence and tips on the use of medication compliance aids
    BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2801 (Published 19 July 2018)
    Cited as: BMJ 2018;362:k2801 Responses)

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  • Julia. Interesting article, but be very careful. I would offer two words of advice....Andrew Wakefield.... Yes, every medication error is unacceptable but when viewed in the context of the official figures of 237 million medication errors in the NHS annually in England alone, my goodness, Houston we have a much bigger problem!

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